Prior Auth Required

11035 - Request Form, F- (07/12)), or PA/HIAS1 (Prior Authorization Request for Hearing Instrument and Audiological

This procedure appears on the selected insurer prior authorization source.

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Prior authorizationPrior Auth Required
Procedure / ServiceRequest Form, F- (07/12)), or PA/HIAS1 (Prior Authorization Request for Hearing Instrument and Audiological
Procedure / Service Description

ForwardHealth Portal or to submit the following via fax or mail - ● A completed PA/RF (Prior Authorization Request Form, F-11018 (05/13)) (or PA/DRF (Prior Authorization/Dental Request Form, F-11035 (07/12)), or PA/HIAS1 (Prior Authorization Request for Hearing Instrument and Audiological Services 1, F-11020 (05/13))). ❍ The provider should mark the checkbox titled "HealthCheck Other Services" at the top of the form.

Likely documents
  • Confirm benefit details
  • Submit clinical notes if requested by the plan
Next actions
  • Confirm the current plan policy before submission.
  • Use the insurer authorization workflow for this listed code.